I was all riled up to get angry over this new paper published in Health Affairs:
The United States spends more on health care than other developed countries, but some argue that US patients do not derive sufficient benefit from this extra spending. We studied whether higher US cancer care costs, compared with those of ten European countries, were “worth it” by looking at the survival differences for cancer patients in these countries compared to the relative costs of cancer care. We found that US cancer patients experienced greater survival gains than their European counterparts; even after considering higher US costs, this investment generated $598 billion of additional value for US patients who were diagnosed with cancer between 1983 and 1999. The value of that additional survival gain was highest for prostate cancer patients ($627 billion) and breast cancer patients ($173 billion). These findings do not appear to have been driven solely by earlier diagnosis. Our study suggests that the higher-cost US system of cancer care delivery may be worth it, although further research is required to determine what specific tools or treatments are driving improved cancer survival in the United States.
So much wrong here. First of all, it uses the old “survival rate”/”mortality rate” swap that I’ve discussed here and here and here and here and here. If you want to show that things are better, study the mortality rate, not the survival rate.
More importantly, there is nothing in this study – nothing – that proves that spending more is what improves things, even if things are better. There’s no causality at all.
So I braced for the worst in the media. But then Sharon Begley became my new hero:
Cancer patients in the United States who were diagnosed from 1995 to 1999 lived an average 11.1 years after that, compared with 9.3 years for those in 10 countries in Europe, researchers led by health economist Tomas Philipson of the University of Chicago reported in an analysis published Monday in the journal Health Affairs.
Those extra years came at a price. By 1999 (the last year the researchers analyzed), the United States was spending an average of $70,000 per cancer case (up 49 percent since 1983), compared with $44,000 in Europe (up 16 percent). Using standard figures for an extra year of life, the researchers concluded that the value of the U.S. survival gains outweighed the cost by an average $61,000 per case. The greater spending on cancer care in the United States, they conclude, is therefore “worth it.”
Experts shown an advance copy of the paper by Reuters argued that the tricky statistics of cancer outcomes tripped up the authors.
“This study is pure folly,” said biostatistician Dr. Don Berry of MD Anderson Cancer Center in Houston. “It’s completely misguided and it’s dangerous. Not only are the authors’ analyses flawed but their conclusions are also wrong.”
Wait… is that actual reporting, and not a rehashing of a press release? More, please!
Philipson is a fellow at the conservative American Enterprise Institute and at the Manhattan Institute, served in the administration of President George W. Bush and was a healthcare adviser to Sen. John McCain’s 2008 presidential campaign.
For the new analysis, Philipson and his colleagues analyzed the survival of cancer patients diagnosed from 1983 to 1999 with any of 13 common cancers, including breast, prostate, colorectal, and leukemias.
Survival means how long a patient lived after being diagnosed. Philipson’s team focused in particular on survival gains; that is, how long did patients diagnosed in later years live compared with those diagnosed earlier in the period? Such gains, they argued, show what progress countries made in treating cancer.
While that may seem straightforward, survival data is among the most problematic cancer statistics, Philipson’s team acknowledges. In particular, they are plagued by something called lead-time bias.
If a tumor is diagnosed very early in its existence – if it has a long “lead time” – the patient may survive, say, two years if the tumor is very aggressive. If an identical tumor is found in that patient’s identical twin later, the twin will survive, say, six months. But the twins die at the same age. The first survived longer with cancer due to lead-time bias, but did not have a longer lifetime.
Crediting medical care with “improving survival” is therefore misleading, cancer experts have long argued. Lead-time bias makes it seem patients live longer, but the only thing that is longer is the number of years they know they have cancer, not their lifespan.
The authors of the “worth it?” study nevertheless base their analysis on survival data. They argue that because U.S. cancer mortality rates fell faster than those in Europe, the survival gains must be real and not an artifact of lead-time bias.
Others call that approach fatally flawed. “Lead-time bias is an issue,” said MD Anderson’s Berry. “I can see no hint of logic in their statement that ‘lead-time bias did not confound our results.’”
Be still my heart. Please, may I have some more reporting?
The researchers acknowledge that it is not possible to conclude that improved survival comes from higher spending on cancer care. It might also come from more widespread cancer screening which, experts say, detects more and more “pseudo-disease” — that is, a tumor so nonaggressive it would never have threatened the person’s health or life. That alone would make the survival data look better.
The Philipson paper was supported in part by Bristol-Myers Squibb Co, whose cancer drugs include Yervoy. A drug for advanced melanoma, it costs $120,000 for a full course of treatment. Clinical trials showed that Yervoy produces a near-miraculous cure for some patients, with a median increase in survival of 3.6 months.
U.S. spending on cancer care has continued to increase, reaching $72 billion in 2004, the last year for which data is available.
The new study did not examine the cost-effectiveness of that care. “In the last decade, spending in the U.S. has increased more than in Europe,” said Philipson. “I would be extremely surprised if the survival gains haven’t continued. But it is a much more open question whether that additional spending has been accompanied by an increase in longevity.”
In the last decade, a number of very expensive cancer drugs were introduced into the United States, including Dendreon Corp’s Provenge for prostate cancer ($93,000 per treatment) and Bristol and Eli Lilly and Co’s Erbitux ($100,000 per year). Their analysis, say Philipson’s team, “does not imply that all treatments are cost-effective.”
Worse, many are not medically effective. Last week, the American Society of Clinical Oncology released a list of five cancer tests and therapies that do not help patients live longer or suffer less — even apart from how much they cost.
Please go read the whole thing. And then start a campaign to get Sharon Begley a raise and a promotion.
UPDATE: Before commenting or emailing me, please go read this follow-up post.